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Credentialing

Regence contracts with physicians, dentists, other health care professionals and facilities to form networks for the delivery of health care services to our members. Providers must first complete our credentialing process before they can participate in Regence provider networks.

Initial Credentialing

Regence requires all providers to meet our credentialing criteria prior to contracting, and remain in compliance with that criteria at all times. Only those applicants licensed in Oregon and Clark County, Washington and in those specialties recognized by Regence will be considered.

Before submitting an application, please review:

Physicians, dentists and other health care professionals

  1. View the Practitioner Credentialing Criteria for Participation and Termination
  2. Complete a credentialing application using one of two methods:
    1. Complete online application using eApply, or
    2. Download and fax paper application (PDF)
  3. Register for the Provider Center
  4. Sign up for eContracting

Please allow two business days for your information to display in eApply before contacting our Credentialing Department regarding the status of submitted applications. If you submit a paper application, your information will not be available in eApply.

Organizations and facilities

  1. Review the Organizational Provider Credentialing Criteria for Participation and Termination for a listing of organizational providers that require credentialing
  2. Complete a Organizational Provider/Facility Credentialing/Recredentialing Application (PDF)
  3. Register for the Provider Center
  4. Sign up for eContracting

Note: Organizational providers that have changed ownership and are required to complete the site survey process by the state and Medicare must be initially credentialed under the new ownership. If the state and Medicare allow the acquisition without the application and site survey process, credentialing may not be required.

Hospital and Free-Standing Facility Based Practitioners

This applies to a practitioner who practices exclusively within a hospital, inpatient or free-standing facility setting. Complete the Hospital and Free-Standing Facility Based Practitioner Information Form (PDF)

Initial Credentialing Process

Upon receipt of a completed application, we verify the information using national and state data sources before reviewing for final approval. Incomplete applications will delay the process.

You will receive an email confirmation once you have passed successful credentialing. You will receive another email when your agreement documents are available online for viewing or signature. This email will contain instructions for accessing the online documents securely through the eContracting Center. Your effective date will be the first day of the month in which the contract was signed.

NOTE: If you practice at a clinic that has a Regence Participating Medical Group Agreement, we will add you to the group’s agreement and no additional documents need to be signed. Your effective date will be the first day of the month in which credentials were approved.

You have the right to correct erroneous information submitted on your application. If you have questions about the process or the status of your application, please contact our Credentialing Department.

A representative from the Credentialing department will contact providers if the credentials are not approved or if additional information is needed. Providers that have been denied initial participation do not have the right to submit an appeal. Refer to the credentialing criteria above for additional information. 

Participating Effective Date Policy

The following policy applies to all participating providers:

  • New provider agreements will have an effective date of the first day of the month in which the credentialing was approved (e.g., if credentialing was approved on June 14, the agreement will be effective on June 1).
  • If a signed agreement is not received in the same month as the credentialing is completed, the agreement effective date will be the first of the month in which credentialing is approved or the signed agreement is received, whichever is later.
  • A new provider joining a group or clinic agreement will have an effective date of the first day of the month in which he or she was credentialed (e.g., if credentialing was approved on June 14, the effective date of participation will be June 1).
  • If a provider already participating with Regence adds an additional network, the effective date of the new network will be the first day of the month the signed agreement is received.
  • Retroactive agreement effective dates are not permitted.
  • Claims submitted for dates of service prior to the agreement effective date will be processed as out-of-network.

Recredentialing

All credentialed providers must remain in compliance with credentialing criteria at all times and must complete the recredentialing process every three years to continue network participation. Providers whose contract status has lapsed more than 120 days will be required to resubmit an initial application.

Please note: Failure to return recredentialing paperwork in required timeframes will result in termination of the provider's network participation. Providers who have their participation terminated will have to wait one year before they can reapply for network participation.

The recredentialing process is initiated by the Credentialing department based on the last credentialing or recredentialing approval date. The recredentialing request is sent six months prior to the recredentialing due date. All providers are expected to respond to this request in a timely manner. Upon receipt, the application is reviewed using national and state data sources. Additional information reviewed may include, but is not limited to, member complaints and quality improvement activities. You have the right to correct erroneous information submitted by another source. Please contact the Credentialing department to learn more.

After completing the recredentialing process, providers will only be contacted by the Credentialing department in the event of an adverse decision or conditional approval status. Providers must agree to these conditions in order for contracts to be maintained.

Providers who have been terminated from network participation have the right to appeal. Refer to the Provider Contract Termination Appeals (PDF) process for additional information. Providers who leave a delegated entity must notify us and are subject to recredentialing guidelines.

Delegated Credentialing

We may delegate credentialing activities to contracted provider groups whose membership includes a minimum of 350 providers. Provider groups must demonstrate the ability to meet our performance standards. Credentialing for organizational providers and facilities cannot be delegated. Regence retains the right to approve new providers and facilities and to terminate or suspend individual providers as necessary and appropriate.

Indian or Tribal Health Clinic credentialing requirements

We require that all Indian or Tribal Health providers complete the credentialing process prior to contracting. These providers are required to complete the recredentialing process at a minimum of every three years.